2012_0601 (5)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE )C_
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
The baclflow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
C Reduced Pressure Principle
Double Check Valve
Manufacturer /,q f r -
Model Number
Serial Number �f
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
/r
Size
Located At
The above is certified to be true.
Firm Name 4 c /i a "t" /' i / -r Certified Tester p ✓� � ' ` A I
Firm Address Pd - i3G x ',79 7 W,4)(4 Cat. Tester No. d f eV OO 7 U �l Date (, -/ - /,,2
Gauge # pG U �-/ I '7 `l 0
Date last accuracy tested q -1,2
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check
tad Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC-Closed,-5, O
Tight Rf
Closed Tight
Leaked ❑
Opened at
osid
Opened at
flsid
osid
RP -_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
osid
Opened at
osid
_____p sid
RP sid
The above is certified to be true.
Firm Name 4 c /i a "t" /' i / -r Certified Tester p ✓� � ' ` A I
Firm Address Pd - i3G x ',79 7 W,4)(4 Cat. Tester No. d f eV OO 7 U �l Date (, -/ - /,,2
Gauge # pG U �-/ I '7 `l 0
Date last accuracy tested q -1,2
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy